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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , � S'tocktou, Calif. <br /> Telephone: (209)` 466-678l <br /> APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES J- YEAR FROM DATE ISSUED Date IssuedtS a_4 --77 <br /> (Compl-ete In. Triplicate) <br /> Application is- hereby made to the -San Joaquin Local Health -District for a permit to construct <br /> heredescribed. This application is made in compliance with San Joaquin <br /> and/or install the work her <br /> Count Ordinance No'. 1$62 an!d -the Rules and Regulations o'f the San Joaquin Local Health :District. <br /> 14 <br /> JOB ADDRESS/LOCATION 1474 W. Linne, Road Trac CENSUS TRACT <br /> Owner's Name Carl Priebe Phone <br /> city <br /> Address s a,me ` <br /> ' Contractor's License <br /> :,.y. <br /> Contractor's Name ®. • � � "o. License # No.27666OPhone 5,279-2020 T <br /> f <br /> k ti <br /> G <br /> TYPE OF WORK,_.(Check).:_ ENEW�.WELL %/ <br /> . DEEREI�--/_=/ R coND-TIo�/�=/ DtS-TRUCT10N <br /> PVMP INSTALLATION/ PUMP/ PUMP REPAIR / / PUMP REPLACEME <br /> ALNT 0 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES 'j PIT PRIVY , <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SIEPAGE. PIT'. OTHER <br /> PROPERTY. LINE = PRIVATE DOME TIC WELL: -PUBLIC. DOMESTIC WELL c` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j, _ . '.Cable Tool `,Dia. of Well Excavation 1 <br /> Domestic/private { Drilled Dia: of Well Casing <br /> Domestic/public Driven -""Gauge-of--'Casing '�a� i <br /> Irrigation Gravel Pack , Depth of Grout Seal <br /> Cathodic Protection � � Rotary Type of Grout <br /> Disposal Other =,Other Information <br /> Geophysical 1Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type.. of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done replace�,l t HP'.subm. Pump <br /> PUMP .REPAIR: / / State Work Done -- T <br /> -- - - Approximate Depth <br /> DESTRUCTION OF. WELL: Well Diameter <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN RAYS <br /> after completion of my work on a new well, I will furnish the Sanf.Joaquin 'Local�Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well. in use. The above <br /> information is true to the-best of my knowledge and -belief. I WILL CALL FOR A GROUT INSPECTION <br /> LPRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED TITLE <br /> RAW PL T PLAN ON RE ERSE SIDE) <br /> 1 <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> t APPLICATION ACCEPTED BY DATE 1 .: <br /> L ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL SPECTION <br /> INSPECTION BY DATE INSPECTION BY TE a <br /> . �< <br /> ,. 3/76 2M <br /> E H 1426 Rev. 1-74 i - <br />